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equip Programme for tonight Brief interventions for alcohol - Angus Henderson Pain pathway - Paula Wilkinson Getting the right patient in the right place – the GP role in Munchausen Chronic Pain and Vitamin D – Subhodha Thanthulage

equip I want to tell you a story John Guy

equip Munchausen syndrome Baron Munchausen 1720 – 1797 Teller of tall tales Riding cannon balls Riding to the moon Pulling himself out of swamp with his own hair

equip Types of behaviour Pretending to have psychological symptoms: for example, claiming to hear voices or claiming to see things that are not really there. Pretending to have physical symptoms: for example, claiming to have chest pain or stomach ache. Actively seeking to make themselves ill: such as deliberately infecting a wound by rubbing dirt into it.

equip How common? 10 of 1300 patients in Canadian hospital study May be more as patients often succeed in deceiving medical staff

equip Tracey Born weeks 1.96kg (37 wks Dubowitz) Parents married shortly after (2 step sisters from mother’s first marriage)

equip 1983 discharged from paeds follow up 1989 tonsillectomy

equip 1994 Withdrawn - referred for paeds opinion Missing a lot of school c/o severe headaches – CT scan normal Breathing problems ?asthma –Responded to pulmicort Eating a concern ?needs referral to Child Psych Dermatitis artefacta

equip 1995 Paracetamol overdose - saw CFCS once (Step sister divorced - 6 children)

equip Pelvic USS normal (1 st ) Emergency admission abdo pain - USS normal (2 nd ); Treated for PID 29.8 Seen by CFCS ‘finding it hard to be listened to regarding her worries

equip Emergency admission dysfunctional bleeding USS normal (3 rd ) Weight loss noted living on bag of crisps and Kit Kat Rx dietary supplements but worried re body image

equip Appendicectomy 14.7.Abdo pain USS normal (4 th ) VVs ligated

equip 1999 Anorexia nervosa 15.1Abdo pain PV bleeding USS normal (5 th ) 2.6Overdose 9 tablets Mefenamic acid in Skegness Tale of man in Essex threatening to assault her 13.6USS normal (6 th ) 1.9‘raped’ under death threat over 9m in Skegness owner of karaoke bar Back injury

equip Satisfies incapacity test 31.3GI endoscopy normal 27.7USS abdo normal (7 th ) 28.7 Overdose admitted to Linden Centre –20 units alcohol per day –3 sisters (went up to 4 sisters by December) 9.11Lumbar spine Xray normal (1 st ) 21.12Married

equip Overdose seroxat 10.04Sought annulment 18.9 Shanie born 2.71kg 28.11Lumbar spine Xray normal (2)

equip USS normal (8 th ) 1.4 Breast augmentation 29.5Lumbar spine Xray normal (3) 20.8 Lumbar spine Xray normal (4) (Radiologist - radiation equiv 260 CXRs) 4.10Admitted with back pain

equip 2002 (cont) 7.10 Told psychiatrist that pain specialist had said her back was broken in 3 places Admitted with retention of urine under orthopaedics (MRI scan T11 to L3 normal) Admitted under orthopods with back pain Xray lumbar spine normal (5) Acute retention of urine under vascular team Seen in OPD mobilising with crutches

equip 2003/ Smoke inhalation house fire Catheter inserted for acute retention 02.04says was told has emphysema - histrionic when chest assessed –CXR normal

equip Mother died aged 59 bronchopneumonia 01.06DSH 20.07USS normal (9 th ) 01.08DSH Facet joint injection Bankruptcy proceedings 01.11infective exacerbation of asthma

equip DSH 1.05TMJ pain 18.06self harm hit hand Dermatitis artefacta 20.11Baby Kelsey born

equip Mirena inserted 01.03OOH Heavy vaginal bleeding post coil fit Seen by Gynae - ward attender OOH Painful abdo lump today Rx Doxycycline USS pelvisNormal (10 th ) mg Depo-med and 5ml LA to abdo wall

equip 2008 (ct) 10.09Right radio frequency lesioning L3 L4 L5 and S Laparoscopic right and left ovarian cystectomy Inconclusive histology 4.11Flexible sigmoidoscopy benign polyp removed

equip 2008 again 5.11USS pelvis (11 th ) 11.11Pain clinic Butrans 10 and TENS machine 3.12Flexible sigmoidoscopy

equip USS pelvis normal (12 th ) 30.03Psychiatrist concerned re prescriptions of opiates 01.05GP concerned re increasing doses of morphine from pain clinic 10.06Joined our list

equip Admitted via OOH headaches and scalp lumps – dermatitis artefacta 02.07Our concern re morphine prescription – noted partner does not work as is full time carer – Secondary gain Noted low threshold for pain

equip 2009 (ct) 13.08Pain clinic – small dose of morphine don’t worry – will benefit from relaxation and hypnotherapy

equip Since joined our list Have talked to each other about the problem – whole team is aware Tried to offer continuity 66 appointments with us to date –26 with main doctor –27 with LG, JG and JM

equip Notes arrived 4 large envelopes Summarised Written to –Psychiatry –A & E –Gynae –Pain Clinic –OOH

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equip Response Very positive from psychiatry Only 3 OOH attendances – mostly just recently so need to reinforce Pain clinic continue to give caudal epidurals 3 so far – notes were missing from main folder when seen

equip Talked to patient Explained that there was no evidence of her ever having broken her back We need to try to avoid harming her with potentially dangerous interventions

equip Remains a challenge We have added 13 th and 14 th pelvic USS 3 lots of TFTs, Chemistry, FBC and ESR 2 CRP 1 HVS / Chlamydia 1 Stool ALL NORMAL 1 Vitamin D level

equip Importance of GP role Only holder of most of the information – no one else can see the overview

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